How to proceed if pt unexpectedly crashes before packaging?

[Jenjas7476825]

Pt presents with acute respiratory distress. Pt postures losing consciousness inside house before packaging/transport. Cardiac monitor shows Accelerated Idioventricular Rhythm.   Now that Pt is unconscious removal  is more difficult due to patient size, 6'2" tall man.  Stretcher outside  Do you begin CPR inside the house?  Or begin removal and begin once you have pt inside rig?  If you know removal is going to difficult and it would delay CPR how would you proceed?

Edited December 23, 2016 by Jenjas7476825

[medicgirl05]

What is the pulse to go with the monitor reading? Is the patient still breathing? Do you have a paramedic on board? Or are you a basic truck?

If you think CPR is necessary, I would start it inside. CPR and early defibrillation should never be delayed. 

[Jenjas7476825]

Previous to cardiac monitor pulse 164, BP 200/110, RR 40, when pt went unconscious there was no palpable pulse, breathing appeared agonal.  One minute after monitor applied pt went astystole.  BLS and ALS on scene.  CPR delayed until in ambulance

 

[medicgirl05]

A fellow paramedic once had a patient go into asystole as the ambulance pulled up to the ER. He chose to disconnect everything and take the patient inside, rather than begin working the code. This caused a delay in CPR, airway management, and the patient did not recover. The ER Dr ripped him a new one. 

Your call sounds similar. 

[paramedicmike]

I'm not sure why this is a question unless you aren't really an EMS provider.

What do you think you should do?

[medicgirl05]

I did worry after posting that this may be someone trying to sue someone.

I also wonder about the accelerated idioventricular rate at 164. That seems strange, but maybe I'm missing something.

Maybe the OP was a basic on the call and doesn't understand everything that happened? 

[Jenjas7476825]

Me personally I would have not delayed CPR.  The problem is once BLS transfers care to ALS what the care plan is is on them.  There was potential for a suit because CPR was unnecessarily delayed by 10 min.  The 164 pulse was what it was before it became unpalpable and before being placed on monitor.  I would have transported post haste.  ALS team does not like having toes stepped on if you don't agree with the plan of action.  ALS was caught off guard and was not prepared.  A 12 lead was not placed.  It was just the cardiac monitor leads so not having a 12 lead ECG the whole picture of what the heart was doing was unknown.  It looks bad when epi and sodium bicarb are administered via the same route....not supposed to be mixed.  the family had no idea how lax the care actually was and it is sad to witness that.

[medicgirl05]

Of course when ALS arrives BLS should step back, and unless I know and trust the BLS counterpart I don't really care what their opinion is. Ultimately whatever happens is on the ALS crew.

Any time I do CPR, transport gets put on the back burner. Either I get a pulse back or I call it in the field.(I do work in a rural area.) 

A 12 lead in this situation is not important, until the patient is stable. A 12 lead while doing CPR is a complete waste of time.

Epi and bicarb can be administered in the same site. Push one then flush, then the other. You shouldn't give one in a line that is an infusion, but the drugs that are given during cardiac arrest should be a push, not a drip. Though the routine use of bicarb is not advised in the prehospital setting.

Go to paramedic school, then you don't have to worry about it. ?

[Just Plain Ruff]

ok, a couple of things,  10 minutes before starting cpr on a pulseless patient - the question is this "did he die?"  I'm sure he did without cpr.  But maybe not.  

Why did they give bicarb? 

 

And finally, Fuck ALS if you disagree with their plan of care,  it sounds like someone should have disagree'd with their plan of care because it cost this guy 10 minutes of CPR and probably cost his family if he did recover, a lifetime of long term treatment issues because SOMEONE decided to wait on CPR until they got to the ambulance thus depriving his brain and heart of oxygen and circulation that should have been started immediately upon him going into arrest.  

Not trying to armchair QB this call but no wonder why ALS doesn't like their decisions questioned, in this guys case, those decisions if questioned would have been right to have been questioned.  

[Off Label]

6 hours ago, Ruffmeister Paramedic said:

ok, a couple of things,  10 minutes before starting cpr on a pulseless patient - the question is this "did he die?"  I'm sure he did without cpr.  But maybe not.  

Why did they give bicarb? 

 

And finally, F*** ALS if you disagree with their plan of care,

Amen, Ruff...but you identify a critical care phenomena that exists in a unique way only in the prehospital setting...and that is on scene pi**ing matches. It's as old as the hills and it is a real problem. Sure, in hospitals, surgeons and intensivists and anesthesia can bump heads about the treatment options for a given situation, but this is in another zip code entirely.

Engine medic v. 3rd service medic, fire als v. private bls on the one hand or fire bailing on the ambulance crew at the worst possible moment on the other. It really looks bad back at the hospital.